Affidavit for Student Living Separate from Parent - Rockwall ISD

ROCKWALL INDEPENDENT SCHOOL DISTRICTAffidavit for Proof of Residency(Student Living Separate & Apart from Parent)Please Print:ATTACH COPIES OF DRIVERS LICENSE FOR ALL PARTIES.Form must be submitted on an annual basis: Year______________________________________________________________________________________________________Student’s Last Name First Name Middle Name Date of Birth GradePlease Complete and Sign Below:I am the parent or court-appointed guardian of the above-named student. The student is under the age of eighteenand lives separate and apart from me as I do not reside within the boundaries of Rockwall I.S.D. I wish to petition theschool district for admission of my child. I understand the Board of Trustees or its designee may make reasonableinquiry to verify a person’s eligibility for admission. [Texas Education Code 25.001( c )]Should the request for admission be granted, I wish to give authority to the following person to be responsible for thestudent’s educational needs (i.e., supplies, fees, attendance, academics, truancy fines, and behavior) while attendingRockwall schools:_________________________________________________________________________ ______________Last Name First Name MI Phone__________________________________________________________ __________________ _________Street City ZipI avow that in the preceding year the student has not engaged in conduct or misbehavior resulting in removal to analternative education program or expulsion; the student has not engaged in delinquent conduct or conduct in need ofsupervision nor is on probation or is on other conditional release for that conduct; nor has the student been convictedof a criminal offense nor is on other conditional release for an offense. (Education Code 25.001)I attest that the student is not attempting to enroll in Rockwall Independent School District for the primary purpose ofparticipating in any extracurricular activity in the District. I understand a student must reside with a designatedcustodian for a period of one full year before the student becomes eligible to participate in competitive events. Ifmedical treatment is needed for the student, the designated custodian (is/is not) authorized to give consent for suchtreatment. I understand that I may revoke this authority by giving written notice to Rockwall Independent SchoolDistrict. I further understand and I agree that I will hold the District and its employees harmless from any claimsmade because of the District’s reliance on this form.I have read the falsification of information penalties on the reverse side of this document and understand it is acriminal offense to present false information to enroll a student in a public school. I agree to notify the school districtof any change in residency status represented in this document. I realize that a lack of proof of residency in theRockwall I.S.D. may result in immediate withdrawal of the student from school.I attest that all information given in this document is true and correct.________________________________________ ___________________________ __________________Parent/Guardian Signature Email Address Date____________________________________ ______________ _________ ________ __________________Street City State Zip PhoneAs the designated custodian, I accept the educational responsibilities set forth above for___________________Student NameI agree that I will notify the District in writing if I no longer wish to accept educational responsibility for the student._____________________________________________________________________Designated Custodian Signature_________________DateParent/Court-Appointed GuardianThe foregoing instrument was acknowledged beforeme________________________________________on this___________day of________________, 20___to certify which witness my hand and seal of office.State of ________________County______________Notary_____________________________________Commission expires_______Designated CustodianThe foregoing instrument was acknowledged beforeme________________________________________on this___________day of________________, 20___to certify which witness my hand and seal of office.State of ________________County______________Notary______________________________________Commission expires_______SFS 12/2012 Page 1 of 2

ROCKWALL INDEPENDENT SCHOOL DISTRICTAffidavit for Proof of Residency(Student Living Separate & Apart from Parent)Falsification of InformationUnder law, if any person knowingly falsifies informationon a form required by the district for enrollment of astudent, that person is liable to the district if the studentis not eligible for enrollment in the district but is enrolledon the basis of the false information. The person isliable for the greater of:1) The maximum tuition fee the district may chargeunder 25.0001 (h)(1)(2) of the Texas EducationCode or2) The amount the district has budgeted for eachstudent as maintenance and operatingexpenses.Also, the district may include on an enrollment formnotice of the penalties provided by 37.10 of the PenalCode and of the liability provided above for falsifyinginformation on the form.The penalties under 37.10 (a penal code dealing withfalsifying government records), are as follows:Any person who knowingly falsifies information on aform required for enrollment of a student in a schooldistrict commits an offense under Section 37.10 of theTexas Penal Code, which offense is a Class AMisdemeanor unless the person’s intent is to defraud orharm another, in which event the offense is a felony ofthe third degree. Further, such person is liable to thedistrict if the student is not eligible for enrollment in thedistrict but is enrolled on the basis of the falseinformation. The person is liable, for the period duringwhich ineligible student is enrolled, for the greater of:(1) the maximum tuition fee the district may chargeunder 25.001 (h)(1)(2), Texas Education Code; or (2)the amount the district has budgeted for each studentas maintenance and operating expenses. A class Amisdemeanor is punishable by a fine not to exceed$2,000.00; confinement in jail for a term not to exceedone year; or both such fine and imprisonment. A thirddegree felony is punishable by a prison sentence forany term of not more than ten years or less than twoyears and additionally, by a fine not to exceed$5,000.00.My affixed signature below confirms Ihave read and understand theprevious law and accept theresponsibility and consequences forfalse information pursuant toenrolling:Student’s NameAs recorded in Rockwall IndependentSchool District.Signature of Parent/GuardianDateSignature of Designated CustodianDateNOTE: Proof of home ownership(contract & utility bill) or a bona-fide leaseagreement and utility bill must accompanythis document along with all partiesdrivers’ license or state ID for verificationpurposes.SFS 12/2012 Page 2 of 2